ࡱ> LNK7  bjbjQQ 43d3dk%%%%%9998q9!XL(,T! ! ! ! ! ! !$x#.&R-!%ttt-!%%B!dddt^%%!dt!ddC  pN0F[  X!0!c ,&& &% dl(dlZlll-!-!dlll!tttt&lllllllll :  Medical Authorized User - Research Date: Name: Department: Office mail location: Phone: Email address: Applicant:  FORMCHECKBOX  Not an Authorized User complete attached Training & Experience Form  FORMCHECKBOX  Currently an Authorized User at 91ɫƵ/FMLH disregard T&E Form Proposed Use: Attach protocol with summary of radiation use. Is the proposed use approved for routine use by the FDA?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If YES, attach Sealed Source & Device Registry information.  FORMCHECKBOX  Attached If NO, does this protocol have an IND#?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If YES, IND#: (protocol must be attached) If NO, attach protocol and IRB application. Send completed application to the Office of Radiation Safety at either of the following locations: FMLH Pavilion Room L760B 91ɫƵ MEB M0760     Office of Radiation Safety Froedtert Memorial Lutheran Hospital 91ɫƵ &'-.1239EFGS`w}   º«wsha hGhGjhGhGUhrhGhr6jr-hGhrU hGhrjhGhrUhGhGhG5 hGhYhGhvB>*hGhY>* hGhvBhMhYhgt>* hY>*hvBhaqhgt5CJaJho5CJaJhgtjhgtU!'(23FG`a ] ^   ^`gdrgdrgdgt$a$gdgt   , < H ] ^ j l A B P Q R  üyni hY>*j*0hgtUj/hgtUjB/hgtUj.hgtUjZ.hgtUjhgtUhgthY hGhgt hGhYhGhG5hGhgt5hrhGhG6 hGhGjhGhGUj-hGhGU( ] ^     v w ^gd5^ & F 88^8gd5^^gdgt & Fgd5^      h5^h5^6CJaJh5^6CJaJhTjhTUhYhY5h5^h5^5h5^     21h:pgt/ =!8"8#8$8% r-DdN  C *Acombinedb,ЩH/,Dn,ЩH/PNG  IHDRc%PLTEU$$U$$IIUIImmUmmUUU۪U$$U$$$$$$U$$$$$I$IU$I$I$m$mU$m$m$$U$$$$U$$$$U$۪$$$U$$IIUIII$I$UI$I$IIIIUIIIIImImUImImIIUIIIIUIIIIUI۪IIIUIImmUmmm$m$Um$m$mImIUmImImmmmUmmmmmmUmmmmUmmmmUm۪mmmUmmU$$U$$IIUIImmUmmUUU۪UU$$U$$IIUIImmUmmUUU۪UU$$U$$IIUIImmUmmےےUےے۶۶U۶۶U۪UU$$U$$IIUIImmUmmUUU۪Un.bKGDH cmPPJCmp0712Hs))IDATx^]MGr6b݇,hY /t 400@·"0}`;̪$%h$*++^|}wdˇۋ >ՙ'C?atw)va@B8a-fbz0^!՟őOhP.q7L302G_ Zs{kbѸ?폮y< tѭ&OŖ7iX/؀zoO9F~Jy}^ook2};F9\z2|X 8WA8]1`ũb|um~X `0ۧ2' Obsr+~ٷp~quYElk/$ɈNږr8rHu͑RDsc402.WC+t ĝW8?6"ٱ(ܰǴΫ/2]3Ԥ?֎>Їe<h%lG'NN3t*wm89o3*v 5J N+3j=^?Q0}¨eS`C~B D'`A6y!z0^x$eA.6ȕGn]lš  ^4<my@ٙ+$N<^3L?ap ?`,OzbWЃ4>;G #ɤDuۅ"|ݦ- *v<\C&l^O)'؅ .٢J|Eù6;1 wc[R^G>dvb3%N#Be6$FhiF?sك9u7!&AZ$ޑ#\$sl8'Nf =bn3FI_Ƙ&ni'ܹĘ=&-J]Niq-!CՌa)*;pQZJU& 4kt8S"_\d.rl m nMJ a `r?Br֓;z2%5%Sn""uQi'p-{\hbWyܑ/G~KZgdk(K72N̻k87m$g.9;n~:~~_1ykg&.jd[Uܨ# Te\)y|A8-rĹBJo/B0m}G4DRH?}x*ÅAMT2x04p(9N[j@" eb[^r`d$G~URqUJ<Řu.oF0>`DQsڀL[2J&(eMaRtKę6#TbDE^ek*_gB S>#P O'9t9lRb/%``]1oH.(2Z]2*e[-VIUrzdU ;ŮɌ'E=nHxAh']v##XH5AG_ ȭL,P IrlҴRs&5/t8kǚl>a<gX 3^xrV5ܦI$']j(Մ!㓟% r[UR.5 @uC*Je'fRԇoc>2ҡ(S8zGd!h >ͬ WF0Cu(E k8GdUgQIsաT9H֨[g9xv =_W/_׷!oR߿}cWXe9+Oyf\~{{/7<ࠔT+gұ=g&*ϟO{uha@@:|{:mެ.>{PgM*|ޑnG! D:Ys**-B ̡̼ՔP*`N `fZŒllTٜpt~hwwzpQVPk1-: jsSi UE&sS=s<(5H-b'l*+yDW~Wo&>MOd:af0 4kb$3w\d>&',3Cvv;NINɡ׎I ?T ~.eƪBL+M;I/rk_碌YיyB}G} B)7h_pBL-u4jS^ku=ᚨ=vqżb̰n.N>H-XS-ܤ@B TtJ'Q ' w=EMōpޓ+Adܼ?cX=_J4f>F2dbG!c3g| k@[jJr,:XT.1&{|}lL=\jvPʊ͸S^t\N.0QhC, h9B݋7wrN{mWHoq[P3# [cyHDl薼ɗ' %Y{uF=DZױư俭l/Ƅ&pg5oJ㓔Ķkۢ!jw͇JbT|~N%roν'IO/n T{"< [0S]n0˻'m~ϨfEҜs#8,d0ӴjPu@W GldyK~p|&%cV>[B ,Z8P AyEE[ GdY&5Jqi'oiLCG:R_p^ZXpcAC(Rakm7 bCs ȨܕW$1X4%~єq P+0O>K9۲߳q%XґSJ76x̗~E$l'76fe&Fo &m8 MI4(ДN?_^ 3i,st^sO3.t6zW+ۍ"=FmtɶiN|assʤ~`v#<`40pɤ /NfQkxs0lQkb"3 >;'ߝϴ,8+G.-#w^N'ι~Pm7\&]iT¨(0[Ak_b; ȼ,k@ORU'+t+ט,]A'q Ɇq;zL +9{,.N!J2 D;{l) L8R>taPF c'LΝRd}RlRV"  ҅rex !QK'z)#զbٱ*UB9sot譬}AK czlǻU,?mrmRM5g$Wd y,#9%!ib 35#Tk>2 7,2E)0Hh ~t?"=ẃ+nsdaV{Bjcgs5;k8T΅׉;H;d e13GbLaIPL3:xTc͙\FEquGo*FR  +'#v6.Z h7y2JP'C> O"ˋ&gڎ<Kn2I<:ݬ٥W`&Ǭ/QǭE/7H-v݌ eV>j4|02ѰS91*Ip<1+=p)#9ca5!5"Vө,(WF1'h-iJmxԾ9Pyz5:R+F支m0i4séq8\HԋVjf{;tڸӖ|-ts|IpftIM$ㄵaM }?Ekڧzc=$f` E_u3-34gIj&tO  Dk &#{hr0Mm󟙷53pf,=Ya͓a2u)pv9ܧOn$E$$%9MϚ)/@54R"`}# dяuGP_3=VC x"A2 bp?֞)c3{čnval!#E Rg1oAiy@9F&C\jJؕ ݦݡR!gqA@v-˾BԿ~9eD5~Yj;'Rb)8KGS':fE>}}N$onD2&P'eF3-9 qD$d]#4JV*/[gKGϼR` *Ypg)tV@u'' R_2<2X[WO6č[^ lu{Z37;nmkbCt <[m /…Ʃ->OR{>jz$ ."ͤEZS+&JluECH%TU: =;[3JJM(C28&SyTa#T!KN=d^tPdLbxO'{WYyU" jlR'5|t˧  0%T`S-EhB=8#)5 u!zR ޲]p,ώ~k/5%hq#GAe@5RPrvoOř_Qtq-` _#ŕJP'o*'2# mř\M/r B-ZV`*fyZė՜7blx'O53Z2G'⫿n}N'0mhdjVA;K~*c)܄=Z^R0Fe]h6%?wzOR n.0s4A%Ow]La0 %ܸ+>ּk,)2-ɷ[9ߓ%<SW$ny[F|mV>{a4*|ck(n9Ke~ϻk7Z1L`28AS h>sCY L2hHv˅<%MOtˁe>M]Z9X~ɨ7~bemUli6  r[}qOs( Vtlv&W+og >yYMŇc b`̫/Z-ℏ ~9`JʁY^.UO$ExaU]Qi#6oI+ePKf}ƫVުA 벓#on+TzUtM7LYT;־3RbdO#B=E vW*9MO_/so Pd0r 1vB9I:1kwEzd2;4;!B2&ZJKPL+I!ohRc軘Nf#_p8ﳬO蘆t)#Uf*}h+y5K<; 4 BeUMF֓VYT؍ߤ~M08AH484/(_KNkVw wt +({"'DD/q\L(Gvױ5 75kM5*"W43Xg),Ys+lJ`ʈGZ#$0C*iD* ehU\?c̰xԴygl;,$p"2R hPe 7vÏ ;0 {dKyb ɲ?q@8b#`izRanh2)?b J JI֋8 ^>Nǰ WDXOaóBDתTse|T]0bOT~H=.IM]oB,B@[W_Xx_8 #*@+jQR/еIu]t8i෻S?dOQ'#%7idfH6pGlb"hcO_33S]J h}+4QcY5&@ nXRYc'%=K\s%NCZw(#c%a>(>kԔLtݫ ,Pφ4%^e8\K;YԺU*BW252)\VP#cMfޕU4oEJ,A̡b;C蹙F: =`PP|Eimӈ@Y6 3x􇎨\leǭ9zM7_yAAk߲TFy6dO!\eZ`[HIgv|QeY'YheLK3niKiA5ClK>fOUK%_Xw?X#VLckd֩e9AqPdFsܙ ^RN {`PC3ԀY*Ch@ݖyx>pdf-2+*0yf,c8J s*MTwJzXAR8sJt5\>hO5Ç2'w/=.P0ďݾEbB2E|B9z|M(eNd^bY_?g!9 ę:}sdLݧXCV4B`NLxE+~9UX4z<Ěu6vzm[ *,qf\>MElO#iO|HdS7X՞3eDu j&ɔCĬp ~L2y~U!I(!j+idK nU~=Yr"57'#|Ov|0[J['",6 X)I#91Ml 5Rᙃ O¤s_sysUo +$tM}%_#=>\k0y~+.FlP$t$ Dqi,ȊTqJmFޓ C Ůt1HY", XĖٌ)9dȳ͓.Č6͸㈧,2M!;A5DKtK50d{(e ٫wBvCL*] 4NXdS_ yY^ۻ5ٜb0S!,A[R2ۼrk"2W)!ŽoI(ʹKҎESKPTesL,@We8͉-'v ɣVsgөyBR ›yyJz,` ʄЌ(-shռ*+a\)|I,Ԅ'(]~ܹs"_md'?20\cU_uw߿{槻o}}VlTf&Pbsk~@\fIך&k7] ~e?0G~<ׇxWUYNԁ'v@1r;N( 6IENDB`tDeCheck1tDeCheck1tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5w2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666_HmH nH sH tH @`@ gtNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 4@4 5^Header  !4 4 5^Footer  !FVF GFollowedHyperlink >*B* phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  jjjjjm       AQG$G$G G G G$G$8@0(  B S  ?Check1Check2Check3Check4Check5BR 5{$6{$7{$8{$9{$:{$;{$<{$={$>{$?{$@{$A{$       9 *urn:schemas-microsoft-com:office:smarttagsState=*urn:schemas-microsoft-com:office:smarttags PlaceType= *urn:schemas-microsoft-com:office:smarttags PlaceName9 *urn:schemas-microsoft-com:office:smarttagsplace ;   &(38GSaART^ &c4nt:^`OJQJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHc4n         Q9ej.T5^wj8ZrvBoGn {B Y*M?@ABDEFGHIJMRoot Entry FN0OData 01Table'&WordDocument4SummaryInformation(;DocumentSummaryInformation8CCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q